Re: Friday afternoon -- follow up care and question NONparticipation in Medicare

[Guest guest]

RE coordination of care

Agree agree!

Every time I think I'm just the "third wheel" in these situations, this is what happens --

Saw man in 70s with wife yesterday; his wife called 2 mondays ago with complaint that pt had high fever but couldn't void. Sent to ER (pt sees nephrologist outpt for "stage 3 kidney disease, which I think is laughable as his creatinine is no higher than 1.7, but with HgbA1c's above 11 who am I to complain about him seeing Neph?), was admitted by my rounder (another FP who works with his dad but 50% of time does hospital work, NH so does my rounds, great guy!), for urosepsis.

Pt seen, and planned discharge as chart said no fever! Wife argues was 102 that night before, turns out "nurse charted wrong."

Also, unknown to us, the pt has had atonic bladder, sonogram did finally show hydronephrosis bilaterally.

Also, you all should know pt presented with osteomyelitis to me once before, immediately hospitalized, and on discharge, pt came back to me to be "fixed."

Now what's amazing about all of this is:

1) When pt/families are perplexed, they come to us -- we are truly the "first line" of defense.

2) Pts think once the data is "in the computer" that everyone knows everything about their conditions and follows everything -- they have no role in this.

3) It's just fine for us to give pts the "option" NOT to be treated, and it is their choice.

Having been in Joanne's exact situation about 5 years ago, when the ER sent a pt to be "followed up" at my office with a pt who initially saw me in florid CHF (he had no insurance, and had declined aggressive f/u for his CAD 7 years before), it's not always better when they finally do go. I spent 8 weeks trying to schedule an echo for him with the local cardiology group -- he finally went back to the ER, was admitted, and came back to office telling me he was going to be put on the "transplant list" at one of the 2 local tertiary care hospitals down town (30 miles my location).

Since he's now on medical assistance, he doesn't see me anymore... I can't afford to get paid only $23 for a visit for him.

Anyway, we all have our lines in the sand.

Question is, if the demand is great enough, will being nonparticipating with Medicare be worthwhile as pts may not pay us?

Matt in Western PA

Friday afternoon

From Drain, With all these discouraging things coming out of health care reform I need to remember what I am here for. I am here late on Friday evening for Mrs. L. She is a 63 year old realtor who came in at 3:30, short of breath with a complaint that she thought she had caught a fungus that had been featured in NPR's stellar coverage of a rare fungal infection (50 people with 8 deaths in three states in the last three years) broadcast about three weeks ago. Since most of the people with the bad fungus didn't die, she didn't come in to me when this started two weeks ago. Ms. L has diabetes mellitus type 2, Hypertension, hyperlipidemia, and has not been to my office for the last three years. I thought she had changed physicians, but she had just decided she would rather go "natural" and was treating herself with cinnamon, hawthorn, valarian, garlic, fish oil, Co10, and condroitin, and other stuff she had read about in various magazines. She was thinking about losing weight but she had a fall and hurt her back, so that didn't happen; and she was seeing a chiropractor about that. Mrs L is in florid congestive heart failure. She had been sleeping sitting up for the last three days. She is home with her Lasix and other meds right now: we are in touch via phone. She won't go to the hospital, although she was willing to get an xray and get real medications. Since she is essentially pharmacalogically virgin, she might be quite responsive to diuretics. She has a list of the totally critical signs that tell her to call the EMTs. Do I approve of Mrs L's self imposed "deferred medical management?" No. Many physicians might have just sent her to the ER right away and had nothing else to do with her, but I think she would not have gone. I had to call her up and harass her to get her meds today rather than waiting until tomorrow. People forget that cardiac problems interfere with cognitive function. This is the third time this year that I have had a person come in on Friday afternoon who I think might have died if I had not been there. So that is my Friday feel good story. I sure needed that, because another of my patients came in to tell me about his old aunt (thank god not my patient) who died up on the hill in her home with her multiple cats, and who was not found for three weeks, and how he needed gloves and a mask because he was assigned to go in and clean up the room(s) she was found in. If you want to know what kind of "medical management" will happen with neglect by big corporations of the insufficiently populated poor rural counties, just think about that for a minute or two. Joanne Holland DVM/MD Drain, Oregon